Neglect

Contents

1. Definition

Neglect is defined in Working Together to Safeguard Children 2015 as "the persistent failure to meet a child's basic physical, emotional and/or psychological needs, likely to result in the serious impairment of the child's health or development. Neglect may occur during pregnancy as a result of maternal substance abuse. When the child is born, neglect may involve the parents or carers failing to:

Provide adequate food, clothing and shelter (including exclusion from home or abandonment);

Protect the child from physical and emotional harm or danger;

Ensure adequate supervision (including the use of inadequate care-givers); or

Ensure access to appropriate medical care or treatment.

It may also include neglect of, or unresponsiveness to, a child's basic emotional needs.

Neglect is characterised by the absence of a relationship of care between the parent/carer and the child and the failure of the parent/carer to prioritise the needs of their child. It can occur at any stage of childhood, including the teenage years".

Neglect can be defined from the perspective of a child's right not to be subject to inhuman or degrading treatment, for example in the European Convention on Human Rights, Article 3 and the United Nations Convention on the Rights of the Child (UNCRC), Article 19.

2. Risks

The impact of Neglect during the first two years of a child's life can have profound and lasting effects on the development of the brain, leading to later problems with self-esteem, emotional regulation and relationships.

A particularly damaging combination for children is growing up in an environment of low warmth and high criticism - that is, parents/carers who switch unpredictably between helpless (neglectful) and hostile (abusive) care.

Neglect can affect children of all ages.

In addition, where parents/carers have specific beliefs, which may involve how the child receives health care and treatment or general nutrition, the outcome can be that the child's health and well-being can be dangerously compromised.

It is important to remember that neglect can be fatal to the child.

"The majority of neglect related deaths of very young children involve accidental deaths and sudden unexpected deaths in infancy where there are pre-existing concerns about poor quality parenting and poor supervision and dangerous, sometimes unsanitary, living circumstances which compromise the children's safety …. these issues include the risks of accidents such as fires and the dangers of co-sleeping with a baby where parents have substance and/or alcohol misuse problems." (Brandon et al, 2013).

3. Indicators

Neglect differs from other forms of abuse in that there is rarely a single incident or crisis that draws attention to the family. It is repeated, persistent neglectful behaviour that causes incremental damage over a period of time.

It is important to avoid 'Start Again' syndrome. Neglect should not only be measured by the most recent set of events but should be judged by the cumulative impact on the child of any previous incidents.

There is no set pattern of signs that indicate neglect other than that the child's basic needs are not adequately met. In this context:

Adequately means sufficient to avoid harm or the likelihood of Significant Harm;

Failure to meet the child's needs does not necessarily mean that the parents/carers are intentionally neglectful, but it does point to the need for intervention;

It is essential to monitor the outcome of intervention - are the child's needs being adequately met after the intervention and is there a sustainable improvement?

The essential factors in demonstrating that a child is being seriously neglected are:

The child is suffering, or is likely to suffer, Significant Harm;

The harm, or risk of harm, arises because of the failure of parents or carers to meet the child's needs;

Over time, the harm or risk of harm has become worse, or has not improved to the point at which the child is consistently receiving a "good enough" standard of care;

Persistent, severe neglect indicates a breakdown or a failure in the relationship between parent and child.

Where there are concerns about standards of care the Graded Care Profile or Neglect Toolkit provides a tool for assessment, planning, intervention and review. This gives an objective measure of the care of the child across all areas of need, showing both strengths and weaknesses. Improvement and/or deterioration can be tracked across the period of intervention. It allows professionals to target work as it highlights areas in which the child's needs are, and are not, being met. It may also help parents/carers who may have experienced neglect themselves to understand why such behaviours are harmful.

4. Protection and Action to be Taken

In supporting a family in which neglect is an issue, the greatest of care must be taken to resist the pressure to focus on the needs of the parents/carers: intervention should concentrate on ensuring that the child's needs are being met. This may require action to ensure that the parents/carers have access to specialist (and if necessary independent) advice and assistance, including assistance in communicating with professionals.

Neglect may arise from lack of knowledge, competing priorities, stress or deprivation. It may also be linked to parents/carers who retain cultural behaviours which are inappropriate in the context in which the family is living.

When a child's needs are unmet because the parents/carers lack knowledge or skill the first choice for intervention should generally be the provision of Early Help services such as information, training and support services. If there is no progress and the assessment by professionals is that progress is unlikely without more proactive intervention a referral to Children's Services in line with the Referrals Procedure should be considered.

Neglect often occurs in a context in which parents/carers are dealing with a range of other problems such as substance misuse, mental ill-health, learning disability, domestic violence, and lack of suitable accommodation.

On many occasions the birth of an additional child may add to the pressure on the family. The parents/carers may provide an acceptable standard of care until a new pressure or an unexpected crisis arises: then they lose sight of their child's needs. In this situation the first choice for intervention should be the provision of support in dealing with the competing pressures. This may require referral to appropriate adult services or family support services.

Messages for Good Practice

Practical resources are often beneficial but their impact on meeting the child's needs must be kept under review;

Neglectful families are more likely to be isolated and to have weak informal networks. Providing volunteer support, and facilitating better relationship with family and in the community, can be effective in raising standards of care;

Dealing with neglect can be overwhelming for professionals: support and regular supervision are crucial;

It is important to carry out regular reviews of the rate at which the required change is being achieved in terms of the child's improved health and development.

5. Important Issues to take into Account in Making Decisions about Neglect

Drift

Neglect is characterised by a cumulative pattern rather than discrete incidents or crises, and so drift is always a potential problem. Drift may result in a loss of focus on the needs of the child, and a change in professional expectations of what an acceptable level of care might be.

Recording

Accurate, detailed and contemporaneous recording by all professionals, and sharing of this information, are crucial to the protection of the child. In any service, professionals should work from a single set of records for each child. All entries in case notes should:

Be factual and evidence based;

Rigorously separate fact and opinion;

Be dated and timed;

Give names and agencies in full; and

State agreed responses and outcomes.

Records should include a detailed Chronology of what has been tried, and to what effect.

Cultural Factors and Neglect

There is a risk of confusion about the difference between style of care and standard of care. Styles of appropriate care vary widely, influenced by gender, class, culture, religion, age etc. It may be difficult to see why the care offered by a particular family does not lie within this range. The common factor in all styles of appropriate care is that they address the needs of the child. Neglectful care may have some factors in common with various styles of appropriate care, but it fails to address the child's needs and falls below an acceptable standard.

Missed Appointments

Non-attendance at or repeated cancellations of appointments and lack of access to the child on visits are indicators that should increase concern about the child's welfare. All NHS providers should have policies for the management of children not brought to medical appointments. If there are concerns about the neglect of a child's health needs, these should be discussed with the named doctor or nurse for the trust, the named GP, or the CCG's designated safeguarding professionals.

Supervision

All agencies should be aware of the need for supervision and challenge of staff who are monitoring cases of chronic neglect:

Professionals often want to think the best of the families with whom they work, and interpret events accordingly;

Familiarity with the family's lifestyle may cause professionals to minimise concerns and accept that the observed standards are normal for this family;

Changing the worker also carries risks as it takes time to see the pattern of events that identifies care as neglectful.

Supervision must provide an independent review, keeping the focus on the child's needs and the adequacy of parenting over time.

If the child appears resilient, professionals should not accept this at face value, but should check for evidence of unmet needs and impaired health and development.

Reviewing Process

When reviewing progress in cases of neglect it is important to look for evidence of sustained improvement in the child's health and development. Where there is a pattern of short-lived improvements, the overall situation remains unsatisfactory - if adequate standards of care cannot be sustained, the child remains at risk of significant harm.

Start Again Syndrome

Professionals must resist the temptation to "start again" at key points such as the birth of a new child or a change of worker. It is important to see current events in the light of the full history of child protection issues, including previous responses to support. The family histories of neglectful families are often complex and confusing, and professionals may be tempted to set them aside and concentrate on the present. This can result in an over-optimistic approach to a family with deeply entrenched problems and neglect of the child's needs.

Focus on the Child

As noted above, neglectful adults are often enmeshed in a complex network of problems. The clamour of the parents'/carers' needs tends to draw professional attention away from the unmet needs of the children. When addressing the needs of neglectful parents/carers, it is necessary to ask repeatedly:

Do they understand what action is needed and within what timescales?

Are they able and willing to meet the child's needs?

Are they doing so?

Are they able to access appropriate support services?

Is anything changing for the child? Is the change enough to bring the standard of care up to an acceptable level?

What is it like to be the child in this situation?

What does the child say about his/her experience;

What does the child's behaviour say about whether his/her needs are met;

If adult services are supporting the parents/carers, it is important to stress the need for them to notify children's practitioners if the parents/carers fail to engage with the services offered.

If there is a vulnerable adult living in the same household as a child whose needs are neglected, then their needs may also be neglected or unmet. Practitioners should report any concerns about the welfare of vulnerable adults to adult social care.

Intentional Neglect

Where there is strong evidence that the parents/carers know and understand the likely effect of their actions or inaction on the child, but intend to cause harm or are reckless as to whether harm is caused to the child, this should be regarded as serious physical and/or emotional abuse. In these cases support is unlikely to reduce the risk to the child. Unintentional neglect should not be confused with deliberate or malicious failure to meet the child's needs in the full knowledge of the potential effects on the child.

One Child Singled Out

Serious Case Reviews have demonstrated that in some instances a child in a family may be singled out and cared for in a manner which amounts to serious neglect. Where a school or other agency raises concerns about the child the parent's response and first assessments of the family may mask the particular treatment in the home of that child, particularly if the siblings appear well and cared for. Assessments where there are concerns of neglect should include speaking to the specific child on their own and viewing their sleeping arrangements.

Neglect by Secondary Carers

This guidance relates only to the child's primary carers. Neglectful care may also be found in secondary carers such as childminders, foster carers, day care or residential settings. In this situation concerns should be reported to:

The child's primary carers, so that they can take appropriate action to protect their child;

The LADO team in Children's Social Care; and

The registration authority for the secondary carer (for example Ofsted), who can consider the possible implications for other children;